You receive a call to a residence for a 6-year-old girl with a decreased level of consciousness. The child has hydrocephalus following surgery to remove a brain tumor and has a ventricular shunt in place. The child's level of consciousness is markedly decreased from its baseline, and the child's caregiver tells you that she thinks the shunt is obstructed. Which of the following sets of vital signs is MOST indicative of shunt obstruction and increased intracranial pressure?
A) Blood pressure 140/92 mm Hg; pulse 58 beats/min; respirations 8 breaths/min
B) Blood pressure 106/66 mm Hg; pulse 80 beats/min; respirations 14 breaths/min
C) Blood pressure 90/50 mm Hg; pulse 110 beats/min; respirations 10 breaths/min
D) Blood pressure 130/68 mm Hg; pulse 70 beats/min; respirations 28 breaths/min
Answer: A) Blood pressure 140/92 mm Hg; pulse 58 beats/min; respirations 8 breaths/min
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A 75-year-old client is admitted to the medical unit for treatment of abdominal pain. Despite the administration of prescribed pain medication, the client reports no relief of pain and continues to describe multiple somatic complaints
The nurse identifies the need for which of the following? A) further assessment and treatment for depression B) review of the client's lab values C) obtaining an order for different pain medication D) contacting the family to talk to the patient
What information would a home care nurse provide to a patient who is measuring peak expiratory flow rate at home?
A) "Although the test is uncomfortable, it is not painful." B) "You will be asked to forcefully exhale into a mouthpiece." C) "The test is used to determine how much air you inhale." D) "You will do this each morning while still lying in bed."
The nurse prepares to administer blood through the client's new peripherally inserted central catheter (PICC). Which is the nurse's priority intervention?
1. Verify the PICC placement with an x-ray. 2. Attach a pressure bag over the blood bag. 3. Measure client vital signs for baseline data. 4. Infuse normal saline solution into the PICC.
A client diagnosed with chronic renal failure asks the nurse, "What's the difference between hemodialysis and peritoneal dialysis?" Which of the following statements best explains the difference?
1. "Hemodialysis is done three times a week and lasts 3 to 4 hours; peritoneal dialysis is done daily." 2. "Hemodialysis uses a graft or fistula and pumps blood through a semipermeable membrane in a hemodialyzer as the filter. Peritoneal dialysis uses the peritoneal lining of the abdominal cavity as the filter." 3. "Hemodialysis and peritoneal dialysis use different equipment." 4. "There are different dietary requirements for hemodialysis and peritoneal dialysis."